Job Description

Job Description

Monogram Health is looking for skilled Nurse Practitioners and Physician Assistants eager for the opportunity to make a difference in patients' lives. The Advanced Practitioner at Monogram Health is a key member of an integrated Care Team which includes a Registered Nurse and a Social Worker. The patients we serve often struggle with multiple serious diseases. Monogram Health is a leading multispecialty provider of in-home, evidence-based care and benefit management services for the most complex of patients who have multiple chronic conditions? 

As a Travel APP, you will be responsible for the delivery of personalized and compassionate care to patients primarily with CKD through ESRD. This specific position will travel throughout the respective geography, connecting with patients and delivering high impact clinical care. Primary duties include patient health assessment, creating strategies to improve or manage a patient's health, and introducing habits for health promotion. In part of completing this care for patients, your responsibilities will include maintaining accurate patient records, scheduling, and administering follow-up appointments to patients. The position will roughly 4 days a week driving to patient homes, and 1 day working telehealth from the APPs home.

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• Ability to travel out of town for up to 80% of the work week - can live anywhere within VA, will travel within state
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• Travels statewide to conduct in-home assessments, which include comprehensive annual wellness exams, focused screenings, or other visits both in the patients' home and in the virtual environment
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• Counsels and educates patients and families about benefits and programs available to help them live healthier lives
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• Documents items such as: appropriate chief complaint, all applicable diagnosis, past medical, family, and social history, review of systems, examinations, medications, allergies, assessment, and plan
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• Responsible for the coordination of care with primary care providers, specialists, and appropriate ancillary services
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• Completes all documentation and paperwork in a timely manner
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• Maintains quality of care standards as defined by the practice
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• This position will not be office-based but will be based in state in which employed and will need to attend periodic training/meetings outside of that state
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• Deliver evidence-based, timely care in a manner that reduces avoidable hospitalizations, maximizes quality of life, and puts patient health and satisfaction first
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• Prescribe medications, order tests, and collaborate with patient’s Monogram physician
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• Perform effectively, as reflected by improved patient quality outcomes, which will be measured and reported daily
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• Facilitates closing gaps in care by educating patients about preventive monitoring and working with physician practices to schedule diagnostic testing
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• Assists patients with enrolling to access educational videos
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• Participates in the integrated care team meetings
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• Knowledge of disease diagnosis and prevention
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• Make assessment of patient's health status
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• Implement a plan consistent with appropriate plan of care
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• Follow-up and evaluate patient's status
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• Other duties as assigned
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• Active and unrestricted Registered Nurse and Nurse Practitioner 
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• Board certified for appropriate licensure (NP: ANCC/AANP)
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• Current and unrestricted DEA certificate, or eligibility
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• Ability to travel extensively across the state to reach difficult to reach patients in their home
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• Ability to work without direct supervision and practice autonomously
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• Access to transportation, a valid driver's license, and car insurance
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• Must be proficient with medical instruments and equipment required by the work
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• Knowledge of computer-based data management programs and information systems, as well as medical records and point-of-interview technology
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• Ability to communicate effectively in verbal and written form with retail and medical partners at various levels, patients, family members, physicians and representatives of the community
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• Sound understanding of all federal and state regulations including HIPAA and OSHA
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• 2 or more years of direct patient care required
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• Comprehensive Benefits - Medical, dental, and vision insurance, employee assistance program, employer-paid and voluntary life insurance, disability insurance, plus health and flexible spending accounts
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• Financial & Retirement Support – Competitive compensation, 401k with employer match, and financial wellness resources
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• Time Off & Leave – Paid holidays, flexible vacation time/PSSL, and paid parental leave
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• Wellness & Growth – Work life assistance resources, physical wellness perks, mental health support, employee referral program, and BenefitHub for employee discounts
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Monogram Health is a leading multispecialty provider of in-home, evidence-based care for the most complex of patients who have multiple chronic conditions. Monogram health takes a comprehensive and personalized approach to a person’s health, treating not only a disease, but all of the chronic conditions that are present - such as diabetes, hypertension, chronic kidney disease, heart failure, depression, COPD, and other metabolic disorders.

Monogram Health employs a robust clinical team, leveraging specialists across multiple disciplines including nephrology, cardiology, endocrinology, pulmonology, behavioral health, and palliative care to diagnose and treat health issues; review and prescribe medication; provide guidance, education, and counselling on a patient’s healthcare options; as well as assist with daily needs such as access to food, eating healthy, transportation, financial assistance, and more. Monogram Health is available 24 hours a day, 7 days a week, and on holidays, to support and treat patients in their home.

Monogram Health’s personalized and innovative treatment model is proven to dramatically improve patient outcomes and quality of life while reducing medical costs across the health care continuum.

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